ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination
1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.
Question 1 of 5
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
| Potential Nursing Action | Indicated | Contraindicated |
|---|---|---|
| Educate the parents to begin range of motion exercises on the affected arm after 1 week. | ||
| Assess for grasp reflex in the affected extremity. | ||
| Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. | ||
| Instruct parents to limit physical handling for 2 weeks. |
Correct Answer:
Rationale: [
,
(0, 1, 1),
(0, 0, 1),
(0, 1, 0)
]
Correct Answer: (
B) Assess for grasp reflex in the affected extremity.
Rationale: Assessing for grasp reflex is indicated to evaluate neurological function and response in the affected extremity. Range of motion exercises (
A) are contraindicated as they may exacerbate the condition. Immobilizing the arm (
C) can hinder normal movement and development. Limiting physical handling (
D) may impede bonding and care interactions.
Extract:
Question 2 of 5
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. In newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its size and relatively lower risk of hitting nerves or blood vessels. This muscle is located on the anterior lateral aspect of the thigh and is recommended for vaccines in infants. Administering the hepatitis B vaccine in this muscle ensures proper absorption and effectiveness of the vaccine.
Choices B, C, and D are incorrect. Massaging the site vigorously can cause discomfort and potential tissue damage. Inserting the needle at a 45° angle may result in subcutaneous rather than intramuscular injection. Using a 21-gauge needle, though commonly used, may not be the most appropriate size for newborns and can cause unnecessary pain.
Question 3 of 5
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
Correct Answer: A
Rationale: The correct answer is A: Depression. Combined oral contraceptives can lead to mood changes, including depression, as a known adverse effect. This is due to hormonal fluctuations caused by the medication.
Choice B, polyuria, is excessive urination which is not typically associated with oral contraceptives.
Choice C, hypotension, is low blood pressure and is not a common adverse effect of this medication.
Choice D, urticaria, is hives or skin rash, which is not directly linked to oral contraceptives. In summary, depression is the correct adverse effect to include in teaching as it is a recognized side effect of combined oral contraceptives, while the other choices are not commonly associated with this medication.
Question 4 of 5
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
Correct Answer: A
Rationale:
Correct Answer: A: You should have your provider refit you for a new diaphragm.
Rationale: It is important for the client to have her diaphragm refitted postpartum due to potential changes in the size and shape of the cervix and vaginal canal. This ensures the diaphragm fits properly and provides effective contraception. Using the same diaphragm without refitting may result in decreased efficacy and potential risks. It is crucial for the nurse to emphasize the importance of seeking a healthcare provider for a proper fitting to avoid complications.
Summary of other choices:
B: Using oil-based vaginal lubricant can degrade the diaphragm material, reducing effectiveness.
C: Keeping the diaphragm in place for an extended period increases the risk of toxic shock syndrome.
D: Storing the diaphragm in sterile water can damage the device and is not a recommended storage method.
Question 5 of 5
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
Correct Answer: C, D
Rationale: The correct answer is C: Bradypnea and D: Vomiting. SSRI withdrawal in newborns can manifest as respiratory distress (bradypnea) and gastrointestinal symptoms such as vomiting. This is due to the sudden discontinuation of the medication after birth, leading to withdrawal symptoms.
Choices A and B are not typical manifestations of SSRI withdrawal. Large for gestational age and hyperglycemia are not directly associated with SSRI use.
Choices E, F, and G are not provided in the question.